Written By: Elizabeth Oler, MD/OB/GYN
I see women of all ages every day with various types of pelvic organ prolapse. Almost every time I meet someone for their first prolapse visit, they are surprised to hear that it is a relatively common issue, because it’s another one of those women’s health conditions that nobody talks about!
Sometimes, women are sent by a primary physician who notices the prolapse, and they don’t have any symptoms. Other times, women notice the prolapse themselves and understandably get really worried. But fear not! Although it seems scary, your OB/GYN is here to reassure you and steer you in the direction that works for you.
At your prolapse consult visit, your provider will perform a pelvic exam and assess which organs are responsible. Many times, people are surprised that their bladder or rectum itself are not coming out – it's the vagina, with those organs behind it. In the case of uterine prolapse, it can be only the cervix that is exposed. Most people have a combination of several different organs prolapsing, but usually one is dominant. Here’s a quick rundown of what might be coming out down there!
Cystocele (aka anterior vaginal wall prolapse): this is caused by prolapse of the front wall of the vagina, with the bladder behind dropping down, so what we see is the anterior, or front part of the vagina.
Rectocele (aka posterior vaginal wall prolapse): this happens when the bowel or rectum is pushing against the posterior wall of the vagina and bulging down.
Uterine prolapse: this is when the cervix is pushing down from the top of the vagina
Apical prolapse: this is what we see after a total hysterectomy, when the uterus and cervix have been removed and it is sewn at the top – also known as vaginal cuff, and the top of the vagina is what’s coming down to the opening.
After your exam, we will go through a picture diagram and explain what level of support, from top to bottom of the pelvic floor, that has been compromised. Once you’ve learned what is happening in your body, you can decide if you’d like to proceed with any kind of treatment. The good news is, prolapse is not a health-threatening condition, as long as you can empty your bladder fully, which is very rare and usually only a concern in the most advanced stage cystocele. Here is a basic rundown of the options available to you for management.
Do nothing: this is honestly ok! As long as you can empty your bladder, we do not have to intervene on your prolapse at all. We will recommend some pelvic floor and core exercises to practice to help improve your symptoms. But otherwise, it is absolutely fine to hold off on management until it becomes life limiting for you.
Vaginal estrogen: Most women with prolapse are postmenopausal and the weakening of the vaginal tissues from loss of estrogen can be uncomfortable. Vaginal estrogen is a very safe and effective option to help mitigate some of the irritation associated with prolapse and is sometimes all a woman will need to feel comfortable enough to manage without more invasive treatments.
Pelvic floor physical therapy/self-directed pelvic floor exercises: Weakening of the pelvic floor muscles and connective tissues is the primary driver of most types of prolapse, which worsens in menopause with loss of estrogen. In some cases, especially in earlier stages of prolapse, just strengthening those tissues can help reduce the symptoms and slow the progression. Rarely does it reverse it, but it can certainly make a big difference, and we recommend continuing pelvic floor exercises even if you decide to proceed with more advanced treatment.
Pessary: a pessary is a device like a diaphragm that is placed vaginally. It can remain there, just like a tampon would, and because it is an inert silicone material, it is generally well tolerated. Just like a tampon, you will feel it when it goes in and out, but once it’s in place, you won’t feel it (if it fits properly of course!) The pessary can stay in place, even for up to four months at a time, and mechanically holds up the organs like a hammock. A pessary can also help if you have stress incontinence (see previous blog post on urinary incontinence in women!) If you decide on a pessary, you will need to come back to the office for a fitting procedure. It almost always takes a few tries to find the right pessary for you. Once you have the pessary, you will need to come back to see us at least every 3-6 months for a pessary cleaning and checkup.
Surgery: there are many forms of surgery for prolapse, and the type of surgery you qualify for depends on your specific prolapse and its severity. Surgery works much better for some types of prolapse than others. Although it seems like an obvious fix, surgery is not always so straightforward, and occasionally, it fails down the line and the prolapse comes back. However, for women who are motivated and willing to follow strict guidelines to prepare and recover, it can be incredibly effective and life-changing. There are some types of surgery that we do at Mercy, and other more advanced procedures that require a specialist in Eugene/Springfield. Your OBGYN will help guide you in the right direction if surgery is your preference.
Hopefully, this rundown helped you understand the “ins and outs” of pelvic organ prolapse! It is truly complex, and always better to get educated on what is happening so you can make the best choice for your health and well being. We are here to help!